The Voxiva Story The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits By C.K. Prahalad Over the last two decades the spread of new diseases such as Acquired Immune Deficiency Syndrome (AIDS) and Severe Acute Respiratory Syndrome (SARS) has generated a renewed awareness of the threats posed by infectious diseases. Indeed, infectious diseases, such as cholera, meningococcal disease, and measles, cause 63 percent of all childhood deaths and 48 percent of premature deaths, and at least 300 million people have acute cases of malaria, 90 percent of them in sub-Saharan Africa.1

Continuing threats of emergent diseases, such as SARS, threaten state and regional economies. In a report issued by the Asian Development Bank (ADB) in the spring of 2003, it was estimated that the SARS outbreak will, in addition to the loss of life, cost Asia approximately $7 billion in forecast economic output while the region as a whole could lose up to $28 billion.² However, disease detection and communication can inhibit the spread of infectious diseases. According to the World Health Organization (WHO), reporting systems are the intelligence network that underpins disease control and prevention. Without this framework in place, it is impossible to track where disease is occurring, measure progress in disease control targets, or provide an early warning system for outbreaks and the emergence of new diseases.³

There are three key ingredients of an effective system for disease surveillance and response:

• Real-time collection of critical information from a distributed network of people, in this case, health workers with new cases of disease to report.
• Rapid analysis of data to drive decision-making and allocation of resources
• Communication back to the field to coordinate response.

Before co-founding Voxiva in March 2001, Paul Meyer founded IPKO, the first and largest Internet service provider in Kosovo. Started in the weeks after the 1999 war, IPKO was hailed by the United Nations Secretary General as "a model for future humanitarian emergencies," and is today one of the largest businesses in Kosovo. Before IPKO, Meyer wrote speeches for President Clinton, graduated from Yale Law School, and deployed IT systems to help reunite refugee children separated from their families in West Africa and the Balkans. After returning from Kosovo, Meyer was a Senior Fellow of the Markle Foundation, where he studied efforts to "bridge the digital divide"—projects using information and communications technologies (ICTs) to support development. He summarized his findings in three general points:

• Most projects were deployed on a pilot basis and were fundamentally not scalable. Making a system work in one village in India is very different from making it work in 600,000 villages in India.
• Projects were overwhelmingly focused on connectivity and devices— building out networks or putting computers in schools—rather than on applications that addressed critical information flow challenges. There was much greater emphasis on machines and data networks and not enough thinking about people and the human networks.
• There was too much focus on the Internet and computers as a solution, particularly given the challenges of electricity, hardware and maintenance costs, training, and literacy.

Voxiva first deployed its technology in Peru to facilitate real-time disease surveillance from rural health workers. The project was funded with a $250,000 grant from the World Bank's InfoDev program. Officials from the Gates Foundation and the WHO suggested Peru as a good place to pilot the system because the country had established a strong paper-based disease surveillance system in the aftermath of a devastating cholera outbreak in 1991. Voxiva wanted to work with a pilot customer who would actively manage the information collected by the system and use the system to respond to disease outbreaks in real time, a role filled by Peru's Department of Epidemiology (OGE). As Johnson emphasized, "The head of the OGE not only understood the role of information technology, but could see the power behind it. We like to work with people who are really hungry for information and actually want to do something with it. We don't believe in collecting data to end up in annual reports. We believe in collecting data for action."

Voxiva also wanted a pilot country where the telecommunications infrastructure had sufficient reach into rural areas. By 2002, telephones had reached more than 6,000 communities in Peru, with Internet access reaching 900. Karen Lynch, Director of the Markle Foundation's Global Digital Opportunity Project, said, "Markle's interest was that [the project] be done in a developing country that showed some critical success factors, such as in-country leadership and an enabling environment, and Peru filled that bill— among other reasons because its president was showing a strong interest in information technology and Peru had put considerable work into its health care administration."


Peru's Ministry of Health: Problem Definition

The fundamental challenge faced by Peru's Ministry of Health was to monitor new cases of disease from more than 6,000 health clinics spread across the country and respond in time to stem new outbreaks. Peru's existing surveillance system collected weekly disease outbreak reports from every health clinic in the country. However, because the reports were collected on paper and recompiled at each level of the Ministry of Health's (MINSA) hierarchy (see Figure 1 below), weeks or months could pass before Ministry of Health officials in Lima learned of outbreaks and were able to respond.

"Previously you couldn't transmit data and therefore couldn't administer data," said Dr. Luis Botton, IT Director at the District Level within the Health System.

Moreover, information rarely, if ever, flowed back to health workers in the field. More than 90 percent of rural health workers reported receiving health alerts "never," rarely," or "less than once a month."

Voxiva's Alerta disease surveillance application was designed to allow for information to flow directly from health clinics into a national-level system so that information is accessible to those at all levels simultaneously. Moreover, the system allows health authorities at higher levels to view the incoming data on a map, analyze it, and use the system's communication and notification tools to provide feedback to the field and coordinate the response.

Figure 1  Hierarchical information flow in epidemiology surveillance from rural clinics to the Ministry of Health in Peru. Data flows up gradually with a paper-based system but no information flows back to health workers in the field.

How It Works

Voxiva designed Alerta to address the needs of Peru's dispersed rural health workers. Alerta allows front-line health workers to submit disease reports in real time from any phone or Internet-connected device. Users receive an account number, personal identification number (PIN) and a plastic card with simple instructions and codes for all the diseases they need to report (see Figure 2). From a phone, they dial a toll-free number to access the system. From the Web, they go to Voxiva's Web site.

Figure 2  Alerta user cards. Health workers enter numeric codes corresponding to the diseases they must report.

The Alerta pilot connected approximately 204,000 individuals in two sparsely populated districts south of Lima to the national health surveillance system: Chilca-Mala with 15 residents per square kilometer and Canete with 24 inhabitants per square kilometer. The system incorporated 76 health clinics, health centers, and district centers (SBS) that are part of the four levels of the Ministry of Health. In total Peru has more than 6,000 health posts (PS); 53 SBSs; 34 state-level health centers (DISA), which play a vital role in outbreak management; along with the Department of Epidemiology (OGE) and the Ministry of Health (MINSA) located in the capital, Lima.

The initial pilot ran from March 2002 through early September 2002. After a short orientation, health professionals began to use available telephones and the Internet (whichever was available) to submit real-time, electronic reports of mandated diseases and disasters. Of the participating health posts, 68.4 percent had easy access to a phone. Another 17.1 percent reported via high-frequency radio link to a nearby clinic. Only 14 percent of facilities had no access to technology and reported using the traditional paper methods.

Prior to Alerta's installation, 28 health posts reported on a weekly basis and 22 reported on a monthly basis to the Chilca-Mala SBS. Although MINSA required that health posts and centers report on a weekly basis, due to the cumbersome process of transporting the reports, many reported only monthly. After Alerta's deployment, 12 of the 22 that had previously reported on a monthly basis began reporting on a weekly basis because of access to a telephone in their village. Of the posts with access to a phone or radio, 86.5 percent reported regularly.

A total of 26,264 cases was reported during the pilot with more than 4,167 calls. Altogether, 204 users, including front-line health workers and management, utilized the program during the pilot. A survey conducted in August 2002 revealed that 90 percent of the respondents who used the system believed the faster responses from supervisors were a primary benefit of the system, and 70 percent of the users cited the increased communication with their colleagues and supervisors as another key benefit of the system.


Cost - Benefit

An evaluation of the pilot by San Marcos University in Peru found that, as compared with the traditional system, Alerta required a substantially lower allocation of resources, lower operating costs, and resulted in a threefold increase in reporting coverage. Overall, the Alerta system required 40 percent lower costs of operations than the traditional paper system. The study also concluded that the use of voice mail for communications was 7.8 times less expensive than written communication.

Alerta's benefits, based on the pilot, can be summarized as follows: (see Table 1 below)

1. It is intuitive to use and accessible, even from very remote regions of Peru.
2. It allows for quicker, better informed decision-making by health authorities and better allocation of scarce resources.
3. It fosters better data quality because data is entered directly by users in the field and validated at the source.
4. It allows for rapid feedback of information to the field and can be used to reinforce the skills and knowledge of health workers in the field
5. It reduces the paperwork burden on health workers in the field.
6. It promotes transparency and accountability by making information available at multiple levels simultaneously.
7. It is cost-effective relative to the current system and other IT rollouts because it leverages the existing telecommunications infrastructure and has an open structure to seamlessly link to legacy systems.
   

Source: Rodrigues, R. J. (2000). Telemedicine and the, transformation of healthcare practice in the information age. In Speakers' Book of the International Telecommunication Union (ITU) Telecom Americas 2000; Telecom Development Symposium, Session TDS.2; Rio de Janeiro, April 10-15, 2000, p. 9

In the words of Dr. Jaime Levano, an Alerta user in Canete, Peru, "We can see the information instantaneously… now everyone is informed about a case and the disease and the appropriate measures can be taken according to the case…i t is truly an important benefit…it could help eradicate diseases."

Alerta represents a fully functional alternative for cost-effective real-time disease surveillance in countries at all stages of technological development. The investment required is small compared to alternative approaches to building disease surveillance, capabilities, particularly in terms of infrastructure and maintenance expenses. The combination of scalable technology, accurate and close monitoring of performance, controlled growth, and effective mechanisms for information sharing, feedback and data-driven decision making has turned this pilot project into a highly innovative, cost-effective and replicable surveillance model.

Although Voxiva's efforts have been directed primarily at delivering health care solutions, because of the flexibility of the technology platform, the company has begun to deploy solutions in additional vertical markets. In the summer of 2003, Voxiva deployed its second application—Citizen's Alert in Lima, Peru— to allow citizens to report crime to municipal authorities in real time and for authorities to track the location of police and dispatch them accordingly. The system was first deployed for the Miraflores municipality in Lima and has since been expanded to four additional municipalities. Like all its applications, Voxiva hosts the solution and charges on a per-citizen, per-month basis.

Although Voxiva's systems were originally developed to serve developing world markets, the simplicity and practicality of the solutions have created demand for the systems in the United States. In the spring of 2002, in the wake of the anthrax letters and broader fears over bioterrorism, Voxiva's board directed the company to explore opportunities in the United States.

Voxiva's first customer in the United States was the FDA. The FDA had developed a Web-based system for monitoring blood shortages but soon discovered that 40 percent of the nation's blood centers did not have ready access to the Internet. In fact, according to a study conducted by the Pew Foundation in April 2003, 42 percent of Americans have not used the Internet, nor do they plan to do so. 7 Because Voxiva's systems are accessible from the phone as well as the Web, the FDA was able to deploy a much more accessible system to track blood shortages (see Figure 3 below).

Voxiva's other U.S. deployments include disease surveillance systems for Washington, DC, and San Diego County and a smallpox vaccination monitoring system for the U.S. Department of Defense.

CHALLENGE: Concern about weaponized smallpox led the Department of Defense to vaccinate military personnel against the disease. Because data on the effects of the smallpox vaccine were more than 30 years old and because of changing demogr aphy and health status of the U.S. population, the Department of Defense wanted to monitor the early recipients of the vaccine closely.

Figure 3   The FDA can monitor blood stortages in real time using Voxiva's system.

Having deployed health solutions on five continents, Voxiva summarized its lessons learned as follows:

1. Foster two-way information flows. Information systems should not just collect data, but also provide feedback and support to health workers in the field. Too often systems are put in place for monitoring and evaluation with information flowing upward to managers but providing no value to the health workers in the field. A well-designed information system supports and contributes to the performance of all the users.
2. Leverage existing infrastructure. It is not necessary to have PCs everywhere to have a robust information system. By leveraging phones, mobile phones, handheld devices and faxes, as well as PCs and the Internet, it is possible to deploy a health information system much more quickly and cost-effectively than systems that require the up-front purchase, installation, and maintenance of a widespread network of expensive hardware or devices.
3. Avoid stovepipes. Information systems should be integrated across programs. With paper reporting systems currently in place, health workers are overburdened with different forms for each program they interact with. In some countries, health workers spend as much as 40 percent of their time filling out forms, compiling data, and copying data. The danger is that those paper stovepipes get replicated with technology and health workers have to use a different system (and perhaps even a different device) for each program they report to (e.g., tuberculosis, malaria, HIV/AIDS, etc.).
4. Software is not a system. Deploying PCs and clinic-level software does not produce an integrated national system. What is needed is a robust, scalable, integrated information system that connects health professionals from the local to the national level and provides them with the information and support they each need. What is needed is more analogous to a sophisticated phone and Web banking system than to Microsoft Excel. This requires a different technology architecture and different approach.
5. Technology alone will fail. Change management and capacity building are key. Most public health agencies in the developing world are not accustomed to real-time information. Helping decision-makers incorporate better information and use it for strategic decision-making and response is critical to the success. This requires considerable change management training, and capacity-building efforts that dovetail with the deployment of an information system.

Although Voxiva's detour through the U.S. market delayed its international expansion, the credibility Voxiva earned from serving customers such as the FDA and Department of Defense has served it well in its subsequent expansion in the Middle East, Africa, and Asia. Customers in new countries seem much more comfortable with technology that is "good enough" for the U.S. market.

Iraq

In Spring 2003, the company won a $1.3-million contract to deploy the national disease surveillance system for postwar Iraq. The contract was part of a larger $43-million contract awarded by USAID to Abt Associates to strengthen the Iraqi health care system. Voxiva's first task order from this contract was to design a platform and database architecture for a facilities-based, real-time Iraqi health information system to strengthen health service delivery and support- project monitoring and evaluation, with rapid prototype deployment of a disease surveillance module in Basra. Voxiva deployed the Alerta system— renamed "SMART" by Iraqi Ministry of Health officials—in January 2004. The company had to expand its standard training to include a new module, "How to use a cell phone," because cell phones had been outlawed under Saddam Hussein and few health officials had even seen one.

HIV/AIDS in Africa

In Fall 2003, Voxiva turned its attentions to the challenges of combating HIV/AIDS in Africa. In his 2003 State of the Union address, President Bush committed $15 billion over five years to fight AIDS in Africa under the President's Emergency Plan for AIDS Relief (PEPFAR). Voxiva believed its solutions were perfectly suited to supporting the huge challenges involved in scaling up and managing the delivery of care and antiretroviral treatment (ART) to millions of people in some of the poorest countries in the world. These were countries where many health clinics lack even electricity, health personnel are limited in number and skills, and information systems are rudimentary.

In December 2003, Voxiva CEO Paul Meyer was invited to accompany U.S. Secretary of Health and Human Services Tommy Thompson, WHO Director J.W. Lee, PEPFAR Director Randall Tobias, the directors of the Centers for Disease Control, National Institutes of Health, Global Fund for AIDS, and the CEOs of Pfizer, Merck, and Bristol-Myers on a weeklong delegation visit to four countries in Africa to plan the PEPFAR implementation. The fact that Voxiva was the only software company on the trip was testament to its rising profile in the arena of global public health.

Based on that visit and on lessons learned from Voxiva's previous experiences, the company proposed a system that would assist clinicians, managers, and decision-makers to:

• Monitor key indicators of a national HIV/AIDS program with accurate, current data for national and global reporting requirements.
• Carefully manage ART to reduce the spread of viral resistance.
• Coordinate services and programs across multiple facilities and levels.
• Provide for the information needs of PEPFAR in a way that is sustainable and strengthens underlying health information and infrastructure.

The system was also designed to improve management of programs by allowing countries to:

• Clinically manage chronic illnesses (HIV/AIDS and opportunistic-infections), including complex treatment regimes.
• Train, support, and supervise health personnel.
• Assure reliable distribution and tracking of pharmaceuticals.
• Promote transparency and accountability at all levels.

• Voxiva seems to have hit on a solution to a universal problem: allowing organizations to collect data from and communicate with dispersed populations in a timely and systematic way by leveraging existing infrastructure. Although the opportunities in front of the company are vast, Voxiva faces a range of challenges as it grows; namely to continue to build the Voxiva brand and reinforce its social capital. Voxiva has benefited enormously from its brand recognition as a provider of practical technology solutions and a socially minded venture. That brand positioning has yielded great advantage for the company in terms of its ability to raise capital; hire, motivate, and retain employees; and attract customers who feel more comfortable working with a company that understands their problems and shares their values.
• Ensure that its capacity to win new business does not outpace its ability to deliver quality services. With operations on five continents, the company will be challenged to maintain the quality of its services. The company cannot afford to let its delivery slip.
• Focus on key opportunities and avoiding distraction. Clearly there is a market for Voxiva's solutions across a range of geographies and sectors. Focus and prioritization are keys. "Saying no to opportunities is a huge challenge," admits Meyer. He constantly finds himself weighing the business opportunities versus the social benefits; short-term results over long-term impact; and fighting the inclination to grow all at once into different sectors.
• Deal with the challenges and long sales cycles of selling services to governments and international development agencies. Voxiva seems to have solved this problem by partnering with officially approved contractors, from Northrop Grumman to Abt Associates to CARE, who subcontract the provision of data collection and communications systems to Voxiva.
• Develop recurring revenue business models that generate revenue from local economies. Voxiva has benefited greatly from its ability to win large, externally funded contracts to enter countries. Without the grant from the World Bank to launch Alerta, for example, it would never have had the resources to enter Peru. However, to build a lasting scalable business, it must develop more solutions like Citizen's Alert in Peru and its patient-monitoring applications in the United States that generate stable recurring revenues.
• Manage a diverse team and foster continuing innovation. One of Voxiva's strengths has been to bring together a team with a diverse background. Voxiva employs medical doctors, software engineers, social scientists, development experts, telecom specialists, change management consultants, and financial analysts. Meyer strongly believes that innovation comes from bringing together people with diverse perspectives and "forcing their brains to work together. It isn't always easy, but it's where the magical insights come from."

Three years after Voxiva's founding, Voxiva is operating on five continents. Meyer still relentlessly challenges his employees to create innovative applications that deliver on two bottom lines: social and financial.

1.  WHO Report on Global Surveillance of Epidemic-Prone Infectious Diseases. WHO/CDS/CSR/ISR/2000.1, http://www.who/int/emc-documents/surveillance/docs/
whocdscirisr200l.pdf/lntroduction.pdf, May 2002.
Note: Cancers, cardiovascular, and respiratory and digestive deaths also can be caused by infections and raise the percentage of deaths due to infectious diseases even higher.

2.  Economic Impact of SARS - From Asian Development Bank, May 9, 2003, http://www.abd.org/Documents/News/2003/nr2003065.pdf.

3.  WHO Report on Global Surveillance of Epidemic-Prone Infectious Diseases WHO/CDS/CSR/ISR/2000.1. http://imuw.who/int/emc-documents/surveillance/docs/
whocdscsrnr2001.pdf/lntroduction.pdf, May 2002.

4.  The World Bank's Agriculture and Development Home Page: http://lnweb18.worldbank.org/ESSD/ardext.nsf/
11ByDocName/AgricultureRuralDevelopment, October 2, 2003.

5.  The Markle Foundation focuses its work in the program areas of policy for network society and information technologies for better health. The overarching goal of the Markle health program is to accelerate the rate at which information technology enables consumers and the health system that supports them to improve health and health care. http://www.markle.org, February 2004.

6.  InfoDev was founded in September 1995, and is a global grant program managed by the World Bank to promote innovative projects in the use of information and communication technologies (ICTs) for economic and social development, with a special emphasis on the needs of the poor in developing countries
http://www.infodev.org, February 2004.

7.  Pew Internet and American Life. "The Ever Shifting Internet Population: A New Look at Internet Access and the Digital Divide." http://www.pewinternet.org/reports/toc.asp?Report=88 April 16, 2003.

This report was written by Cynthia Casas and William C. Lajoie under the supervision of Professor C. K. Prahalad. This report is intended to be a catalyst for discussion and is not intended to illustrate effective or ineffective strategies.